Open Access

Research Mozambique field epidemiology and laboratory training program: a pathway for strengthening human resources in applied epidemiology Cynthia Semá Baltazar1,&, Cátia Taibo2, Jahit Sacarlal2, Lorna Gujral3, Cristolde Salomão1, Timothy Doyle4 1

National Institute of Health, Maputo, Mozambique, 2Faculty of Medicine, Eduardo Mondlane University, 3National Public Health Directorate, Ministry

of Health, Mozambique, 4Centers for Disease Control and Prevention, Mozambique &

Corresponding author: Cynthia Semá Baltazar, National Institute of Health, Maputo, Mozambique

Key words: Mozambique, field, epidemiology Received: 27/06/2017 - Accepted: 12/07/2017 - Published: 31/07/2017 Abstract Introduction: In the last decades, Mozambique has been undergoing demographic, epidemiological, economic and social transitions, which have all had a notable impact on the National Health System. New challenges have emerged, causing a need to expand the preparation and response to emerging disease threats and public health emergencies. Methods: We describe the structure and function of the Mozambique Field Epidemiology Training Program (MZ-FELTP) and the main outputs achieved during the first 6 years of program implementation (consisting of 3 cohorts). We also outline the contribution of the program to the National Health System and assess the retention of the graduates. Results: The MZ-FELTP is a post-graduate in-service training program, based on the acquisition of skills, within two tracks: applied epidemiology and laboratory management. The program was established in 2010, with the objective of strengthening capacity in applied epidemiology and laboratory management, so that events of public health importance can be detected and investigated in a timely and effective manner. The program is in its seventh year, having successfully trained 36 health professionals in the advanced course. During the first six years of the program, more than 40 outbreaks were investigated, 37 surveillance system evaluations were conducted and 39 descriptive data analyses were performed. Surveillance activities were implemented for mass events and emergency situations. In addition, more than 100 oral and poster presentations were given by trainees at national and international conferences. Conclusion: The MZ-FELTP has helped provide the Ministry of Health with the human and technical resources and operational capacity, to rapidly and effectively respond to major public health challenges in the country. The continuous involvement of key stakeholders is necessary for the continuation, expansion and ongoing sustainability of the program.

Pan African Medical Journal. 2017;27:233. doi:10.11604/pamj.2017.27.233.13183 This article is available online at: http://www.panafrican-med-journal.com/content/article/27/233/full/ © Cynthia Semá Baltazar et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com) Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net) Page number not for citation purposes

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in

Introduction

Epidemiology

and

Public

Health

Interventions

Network

(TEPHINET) [6, 7]. The African Field Epidemiology Network The epidemiological profile of Mozambique is characterized by infectious diseases that are closely related to poverty and other socio-economic factors prevailing in the country [1]. The major causes

of

morbidity

and

mortality

are

malaria,

HIV/AIDS,

tuberculosis, respiratory diseases, diarrheal disease, measles, and meningitis [1, 2]. The country is vulnerable to natural disasters (e.g cyclones, floods) and frequent outbreaks of infectious diseases. Outbreaks of cholera and other epidemic diseases recur every year [3, 4]. Currently, the country is facing a demographic transition,

(AFENET)

was

established

in

2004,

after

recognizing

the

opportunities on the African continent for improving epidemiologic capacity through a network of country and region-specific training programs [8-10]. The MZ-FELTP is a member of the AFENET and TEPHINET professional networks. Connections and collaborations within these professional networks have gradually strengthened since the initiation of MZ-FELTP. These networks are a professional and scientific platform for the exchange of knowledge and experience.

with non-communicable diseases increasing in frequency, adding pressure on the health system [2]. The epidemiological surveillance system was first established by the Mozambican Ministry of Health

Methods

in 1979 and underwent revisions in 1985 and 2005 [1]. There were two assessments of the surveillance system, one in 2001 and the

This manuscript describes the program and includes a review of the

other in 2006. Among the identified constraints of the surveillance

main outputs. The outputs include outbreak and field investigations,

system was the lack of human resource capacity of health personnel

surveillance

for disease surveillance, reporting, data management, public health

documentation of standard laboratory procedures, conference

preparedness and response [1, 5]. Timely response to infectious

presentations, training activities and publications. The proportion of

disease outbreaks still challenges the National Health System [1]. In

graduates retained in the National Health System was also

addition, there is an insufficient number of qualified public health

assessed.

system

evaluations,

descriptive

data

analyses,

professionals and they are not equitably distributed throughout the country [1, 2, 5].

Results Furthermore, few health professionals in the country are using epidemiological skills, such as routine analysis and presentation of data. The Mozambican Ministry of Health thus identified the need for

training

epidemiologists

of and

multidisciplinary laboratory

technical

technicians

are

teams

where

members

of

surveillance and outbreak investigation teams. In this context, the Mozambique Field Epidemiology and Laboratory Training Program (MZ-FELTP) was created in 2009 by the National Institute of Health (INS), in partnership with the National Directorate of Public Health (DNSP) and the Faculty of Medicine of Eduardo Mondlane University (UEM), with technical and financial support from the U.S Centers for Disease Control and Prevention (CDC). Similar to other Field Epidemiology Training Programs, the MZ-FELTP is modeled on the Epidemic Intelligence Service (EIS) of the CDC. The EIS was modeled on a post-graduate residency program. It combined classroom and applied training and mentored in-service activities to train professionals in applied epidemiology and disease control, through the motto of "learn by doing". A global network of programs was established in 1997 as the Global Training Programs

FELTP training model in Mozambique: The aim of MZ-FELTP is to build epidemiological capacity in public health surveillance, disease control and response to outbreaks and public health emergencies through training in applied intervention epidemiology and laboratory management. To do this, the MZ-FELTP provides both a short-term, basic course and an advanced master's level course, affiliated with UEM. The master's course is 2 years duration, with approximately 25% of the time spent in classroom modules at the UEM Department of Microbiology and 75% spent in field placement activities. The classroom portion is organized into four modules (Introduction to Public Health and Basic Epidemiology, Scientific

Communication

and

Research Processes, Advanced

Epidemiology and Laboratory Management in Public Health and Management and Leadership in Public Health) with each module lasting approximately 3-6 weeks. The remaining 75% of time, residents are placed in field sites where they develop their skills and competencies in core activities of learning through supervised dayto-day activities at their field site. Field sites are strategic locations

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such as provincial health departments, national programs (malaria,

objectives, training quality, finances, trainee recruitment and

HIV, non-communicable diseases, neglected tropical diseases and

program advocacy.

others), central cross-cutting departments at the Ministry of Health (epidemiology department and others) and reference laboratories at the

National

Institute

of

Health

(tuberculosis,

Timeline of key developments of the MZ-FELTP

serology,

microbiology, virology and molecular biology) and other key areas

Short courses in basic epidemiology: The aim of the basic

related to health (e.g Department of Animal Sciences).

epidemiology short course is to strengthen basic public health surveillance

at

the

district

level,

providing

staff

with

the

During the master's program, each resident is assigned a mentor

epidemiological tools to solve problems in the community. The first

who guides the resident during the two years of training. Mentors

short course was initiated in 2009, targeting district-level health

help review the resident's work outputs and provide technical and

professionals

professional guidance. At each field location, a field supervisor

surveillance activities, outbreak control and laboratory activities.

provides ongoing day-to-day oversight on the experiential learning

Several additional courses were conducted in subsequent years

activities. A two-day training is offered for the mentors and

(Table 1). In general, selection of the participants in the course is

supervisors every year, where their roles and responsibilities are

the responsibility of each Provincial Health Directorate (DPS). The

described. The FELTP coordinating group performs regular field site

course generally has 20-25 participants and a duration of two

visits and meets with both mentors and supervisors to ensure

weeks, except for the first two short courses that were three

ongoing coordination and support of the training process. Residents

months duration with a field work component and mentorship. In

enrolled in the master's program are placed in one of two tracks,

the first four short courses, the participants came from several

based on their background, experience and future professional

provinces and the course was held at the central level (Maputo

goals. These are the epidemiology track or laboratory management

City). However, the approach was changed during the fifth course,

track. During the two years, residents in both tracks acquire

where the training was held in each province and with only

expertise in epidemiological methods, biostatistics, public health

participants of that province (Table 1). In addition to reducing the

surveillance,

public

health

laboratory

practice,

who

regularly

participate

in

epidemiological

scientific

costs of the course, this also allowed course content to be more

communication, management and leadership and emergency

focused on the health priorities of each Province. The longer-term

response.

training plan for the epidemiologic short courses in Mozambique envisions one to two courses per year in different regions of the

Classroom modules make extensive use of case studies and practical

country, so that each province is reached every three to four years.

exercises. Additional training methodologies include topic specific workshops, seminars and journal clubs. Residents are evaluated

Advance course-masters level: The 2-year advanced, master's

through written tests and evaluation of their program outputs. In

level FELTP course was implemented in August 2010, with the first

addition to the academic activities of the four core modules, the

residents enrolled in the program. The first group was composed of

curriculum is flexible to include additional training opportunities on

11 residents, of which five enrolled in the epidemiology track and six

specific issues. There have been several training activities on

in the laboratory track (Table 2). Several residents in the first cohort

specific topics including workshops on non-communicable disease,

participated in the 2009 epidemiology short course and in this way,

risk communication, molecular epidemiology of infectious diseases,

the different levels of training are designed to be synergistic with

scientific writing, HIV/AIDS and geographic information systems

one another. In March 2012, the second class cohort began with 14

(GIS), among others. The MZ-FELTP is governed by an Executive

residents, of which nine were enrolled in the epidemiology track and

Steering Committee that is led by the National Public Health Director

five in the laboratory track. The third cohort started in March 2014,

and includes senior-level officials from the Ministry of Health (MoH).

with 12 residents (eight in epidemiology track and four in the

The steering committee also includes representatives from key

laboratory track). Enrollment in the program is based on a

partner organizations such as CDC, WHO and UEM. This steering

competitive process where MoH first announces the call for

committee meets once or twice a year and has the role of advising

applications in major newspapers. Then selection involves review of

and guiding the program on issues related to the program

application materials and evaluation of applicant skills by a selection committee made up of program staff and key stakeholder

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organizations. The master's degree is provided by UEM Faculty of

National Health System (Table 2). Of the 37 students who enrolled

Medicine.

in the three cohorts, 36 (97%) successfully completed the program. All graduates were allocated to the national health system, through

Program accomplishments: Although the MZ-FELTP is a

different programs at central and provincial levels, at the National

relatively

notable

Institute of Health reference laboratories and at the Ministry of

strengthening of human resources in the health system in

Defense (Military Hospital Laboratory of Maputo). In addition, two

Mozambique.

to

residents were sponsored by UEM and they continue working there.

epidemiological necessities such as conducting more than 40

An external assessment was conducted in 2013 using a scorecard

outbreak investigations and 37 surveillance system evaluations.

that was developed by CDC and applied to FETP/FELTP evaluations

Other important field activities conducted by program participants

in multiple other countries. The tool includes five domains relevant

include: independent monitoring of a mass polio vaccination

to successful FELTP implementation: training, field work, leadership

campaign; evaluation of coverage and impact of a malaria bed-net

development, management and sustainability. The assessment

distribution campaign; response to natural disasters such as

evaluated the implementation and performance of the program and

catastrophic flooding and surveillance during mass gatherings (Table

identified key areas for program improvement. Further program

3). The MZ-FELTP program has also enhanced Mozambique's

evaluation at periodic intervals is anticipated, as is done with other

contribution to the dissemination of epidemiological information

FELTP programs globally and those accredited through TEPHINET.

young The

program, program

it has

has

contributed

been

able

to

to

respond

through the publication of 11 articles published in the MoH Epidemiological Bulletin related to outbreak investigations and descriptive analyses of surveillance data (Table 3). There have also

Discussion

been approximately 100 oral and poster presentations at national and international scientific conferences; four manuscripts were published

in

international

journals

[11-14],

with

additional

manuscripts in preparation or in press. The MZ-FELTP residents played a key role in important field activities. This includes supporting public health surveillance for mass gatherings during the All-African Games held in Maputo in September 2011, through the implementation of a syndromic surveillance system. Residents coordinated the collection, compilation and epidemiological analysis of data from the major health service centers during the event to detect and respond in a timely manner to any outbreaks that might occur. In this case, no outbreaks or unusual disease patterns were identified; however, the activity provided valuable information and reassurance to event organizers and the public during a complex mass-gathering. In addition, catastrophic flooding affected Gaza Province in 2013, resulting in the displacement of an estimated 120,000 inhabitants. During this natural disaster, MZ-FELTP residents conducted real-time surveillance for events of public health importance affecting the displaced population. Increases in diarrheal disease and malaria were noted among the displaced population and this real-time surveillance informed emergency response agencies and facilitated timely implementation of disease control and response measures. An important indicator of success of the program is the graduation and retention of graduates in the

Following establishment of the program, progress has been made in strengthening the response to outbreaks and improvements of disease surveillance systems and activities in the country. The majority of MZ-FELTP graduates have been retained in the Mozambique Health System. This is similar to the FELTPs in other African countries [10, 15-17]. Although there is strong graduate retention, the Ministry of Health needs to further develop a welldefined career path for the graduates in epidemiology and public health laboratory management, to optimize the impact and utility of this human resource cadre and ensure ongoing retention. The program's sustainability is an ongoing challenge, since it is an intensive training program requiring significant human and financial resources. Currently, FELTP in Mozambique is mostly funded by the CDC, with some contributions from the Ministry of Health. The longterm success of FELTPs depends on their sustainability [16], thus the government entities and institutions in host countries must assume ownership of the program and diversify funding with multisector support. One of the priorities is the strengthening of field placements to ensure that the development of skills and competencies are in-line with program objectives and academic training goals. The existence of mentors and qualified field supervisors is crucial for the success of this training model. The limited dissemination and communication of research results through publication in international and national journals suggests

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the need to create strategies for strengthening scientific writing.

Authors’ contributions

However, language also poses a challenge which has been addressed through support of technical advisers who are native English speakers who can review outputs.

All the authors have read and agreed to the final manuscript.

Acknowledgments

Conclusion Epidemiology is an essential pillar of public health and as such, must be closely linked to policies, programs and services. While MZ-FELTP is still at a relatively early stage in its growth and development, it has shown some positive and significant impacts which are assisting the country to better detect and respond to outbreaks and address major public health challenges. It is an important platform for developing a multidisciplinary and cohesive workforce, with trained health professionals that can operate effectively in various segments of the public health system to improve health security. Continued engagement and involvement of all stakeholders and program

The authors would like to acknowledge all organizations that provide support and funding to the program: the U.S. government via CDC, the Presidents Malaria Initiative (PMI) and the Presidents Emergency Plan for AIDS Relief (PEPFAR); AFENET, TEPHINET, South American Network of Field Epidemiology (RedSUR), Applied Epidemiology Training Program of Brazilian Health System (EPISUS) and

Mozambique

Provincial

Health

Directorates.

We

also

acknowledge the following individuals who contributed towards the development of this paper: Eduardo Samo Gudo, Mohsin Sidat, Palha de Sousa and Nick Schaad.

partners is necessary to ensure sustainability and expansion of the program beyond its current scope.

Tables

What is known about this topic

 

The FELTP curriculum has been adopted in many African

Table 1: Implementation of 8 basic epidemiology short courses,

countries to strengthen the public health system;

Mozambique, 2009-2015

The FELTP model is unique for its emphasis of on-the job

Table 3: Major outputs of MZ-FELTP, 2010-2016

training methodology prioritizing "learning by doing";



Table 2: Current profile of MZ-FELTP graduates

The program has been documented for providing an effective response to public health emergencies, including disease outbreaks and other public health events.

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What this study adds

 

This is the first article describing the experience of FELTP

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Table 1: implementation of 8 basic epidemiology short courses, Mozambique, 2009-2015 Year

Number

of

participants

Target Provinces* Maputo Province, Maputo City,

2009

24

2010

18

2012

26

2012

24

Maputo Province, Gaza

2013

20

Cabo Delgado

2014

18

Niassa

2015

25

Zambézia

2015

25

Nampula

Total

180

Gaza, Cabo Delgado Maputo, Gaza, Sofala, Nampula, Zambézia and Niassa Maputo Province, Maputo City and Gaza

*8 of 11 provinces covered

Table 2: Current profile of MZ-FELTP graduates Current Position (in 2017) Provincial Cohort

Track

Admission

Completed

MoH

Cohort 1

Epi

5

4 (80%)

2

(2010-12)

Lab

6

6 (100%)

Cohort 2

Epi

9

(2012-14)

Lab

Cohort 3

Epi

(2014-16)

Lab

Health

UEM

MoD

NGO

2

0

0

0

5

0

1

0

0

9 (100%)

7

2

0

0

0

5

5 (100%)

2

1

1

1

1

8

8 (100%)

2

4

0

1

1

4

4 (100%)

1

3

0

0

0

36

19

12

2

2

1

(97%)

(51%)

(32%)

(5.5%)

(5.5%)

(2.7%)

Department

Total Percentage

37

UEM: University Eduardo Mondlane MoD: Ministry of Defense NGO: Non-government organization

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Table 3: Major outputs of MZ-FELTP, 2010-2016 Outputs

Quantity

Outbreak investigations and response

42

Topics Measles, cholera, rotavirus, typhoid, polio, poisoning, shigellosis, influenza, conjunctivitis, malaria, dengue, chikungunya, and yellow fever Evaluation of polio and measles vaccination campaigns, evaluation of

Field work (Non-outbreak investigation)

6

mosquito nets distribution campaigns, response to emergencies and surveillance at mass events (African Games) Cancer, TB-MDR, antimicrobial resistance, water and food, vaccine coverage

Descriptive

analyses

of

surveillance data

39

, measles , rubella, occupational health, leprosy, exposure to HIV, nutrition, neonatal tetanus, lymphatic filariasis, malaria, cholera, community health workers, non-communicable disease, and neglected tropical diseases

Articles in the Epidemiological Bulletin Creation of database Creation

of

standard

14

Outbreak investigations and descriptive surveillance data analysis

8

Laboratory information system

27

Laboratory procedures

laboratory operating

procedures AFP, measles, HIV anti-natal surveillance, TB, malaria, water and food, Surveillance

system

evaluation

37

polio, lymphatic filariasis , non-communicable diseases , mortality, dysentery, cholera, diarrhoea, immunization coverage, leprosy, laboratory information system, trauma, International: AFENET, TEPHINET, EPISUS

Oral presentations at scientific conferences

>70

National:

Mozambique

National

Scientific

Conference

on

Health,

Mozambique Ministry of Science and Technology Conference, Maputo Central Hospital Scientific Conference, UEM Scientific Conference on Health Scientific Conference, INS Open Days for Research

Poster

presentations

scientific conferences

at

>30

Training activities

>24

Journal publications

4

International: AFENET, TEPHINET, EPISUS National: Health days, MCT, HCM Workshops: Non-communicable diseases, risk communication, molecular epidemiology of infectious diseases, scientific writing International peer-reviewed journal

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